Provider Demographics
NPI:1851849699
Name:WEST, CORLISS
Entity Type:Individual
Prefix:
First Name:CORLISS
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 N COMMERCE PARK DR STE 318
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-3187
Mailing Address - Country:US
Mailing Address - Phone:513-761-0158
Mailing Address - Fax:
Practice Address - Street 1:1 N COMMERCE PARK DR STE 318
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-3187
Practice Address - Country:US
Practice Address - Phone:513-761-0158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.110131101YA0400X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0143878Medicaid